The culture that is Republican

House Republicans signaled Thursday they will not follow rules in President Obama’s healthcare law that were designed to speed Medicare cuts through Congress.

The House is set to vote Thursday afternoon on rules for the 113th Congress. The rules package says the House won’t comply with fast-track procedures for the Independent Payment Advisory Board (IPAB) — a controversial cost-cutting board Republicans have long resisted.

Evil Obama wants to cut the entitlements of the doctors and medical corporations to pick taxpayer pockets directly and indirectly via government payments, and the Republicans are defending their entitlements.

Republicans want to cut off health care as an entitlement to the 47% who always vote Democratic, but make Obama do the cutting, so the Democratic voters will not vote or vote Republican.

That is not quite right. A long time ago a bunch of idiots from both parties had the brilliant idea of allowing doctors and medical corporations to have direct access to tax payers’ money. On a more or less honor basis. This has caused problems.

To fix this flaw, Obama wants more regulation to stop good doctors earning too much. The Republicans want to keep a pretence of a market system. Where costs would be kept down not through Death Panels, but through competition.

So basically both recognise they have screwed the pooch, and both want to fix the problem, but Obama wants to impose new unforeseen consequences to make up for the previous unforeseen consequences, while the Republicans are in denial about said unforeseen consequences. I don’t see much partisan benefit to either side here.

And of course if Obama was serious about health care reform he would do something about trial lawyers like John Edwards making millions out of non-problems and ensuring everyone pays more. But he won’t because trial lawyers give a lot of money to the Democrats.

I did not notice any suggestion in what I said. Although if you are referring to the problems with trial lawyers, the billions they make come from people’s health insurance so obviously restricting their ability to lie to juries – which is what Edwards did professionally – would reduce costs.

If competition did not reduce medical costs it would be a world first and worth a Nobel prize to explain why. The best reform America could do is move away from employer-provided health care towards individual-based systems. Something like Singapore’s mixed system for instance. Because with the employer-based system, the employer has little incentive to pick the best policy and the employee has little incentive to use appropriately.

How much money could malpractice reform save the state? An estimated $600 million to $700 million, according to Kolmer. “But you can’t just focus on containing cost because that’s only about two percent of the health care system. You have to take patient safety and quality improvement into account as well.”

This is despite the fact that the “reform” they are offering is trivial and pointless. It is not stopping malicious and frivolous cases going to Court. You just have to talk about it (and the doctor admit guilt) first.

It is simple. Trial lawyers are making out like bandits on basically baseless and dishonest cases. John Edwards for instance made hundreds of millions out of suing doctors for cyctic fibrosis or patient suicides. That money came from somewhere, or to be more specific it came from everyone else’s premiums.

From one of the first links I googled:

In 2005, Missouri capped non-economic damages at $350,000 per defendant and made it more difficult for cases to be filed in Jackson County and St. Louis — venues seen as favorable to plaintiffs.

“From my perspective, that was one of the best things ever to happen in the state of Missouri,” said Kansas City ophthalmologist John Hagen, an outspoken supporter of tort reform. “It not only enabled us to retain physicians but to recruit new ones.”

Since the 2005 reforms in Missouri, malpractice premiums at Hagen’s practice have fallen 24 percent — a decline he attributes to the reforms. Reintjes said his premiums have declined 30 percent.

And it is not the cost of litigation that is such a problem, it is the cost of defensive medicine.

A sensible tort reform would be to return to previous legal practice – medical evidence should not be accepted unless they are mainstream, speculative future costs should not be admissible and best of all, ambulance chasing should once again be illegal.

Now, I know nothing about whether malpractice cases, and John Edwards’ in particular, are based on “lies.” Maybe we should do something to better scrutinize the claims in these suits. If you are talking about setting some reasonable evidentiary standard, sure.

” What evidence is there that competition in medical coverage will save money?”

Evidence is the fact that single-payers have to create death panels, NICE, effectiveness panels, etc. That is to say, non-competition doesn’t organically cut costs, they have to create artificial strong-arm policies to do it.

Jan, I do not accept that free markets crowd out the sick and the poor and so leave them to die. On the contrary, the wealthy pay for the infrastructure and research that have saved billions of lives. America single handedly subsidizes the rest of the world by paying full price for most medicines.

But if so, how do you think the free market works to deny treatment to the poor? If, as you seem to be saying, competition does not reduce costs? Surely you cannot hold both opinions at the same time unless you think doctors are bastards who like to see the poor die. Do you?

SMS, if you don’t see how an unregulated health insurance market is detrimental for the poor, I guess it would be impossible to convince you otherwise. The question is free markets versus what? A totally unregulated health care market in the U.S without public programs would be…better for everyone?

We have a social insurance program in the U.S. with the ability to cover all the aged–not just the moneyed and healthy. There is the potential to do it much more cheaply. It simply comes down to whether you believe in a program that ensures equitable coverage for everyone, and it seems that you don’t. I could get into why health care is not a free market good and so cannot be treated as a commodity, but I assume you know the reasons and reject them.

Jan, you are shifting the goal posts. It is not whether it is detrimental to the poor, but whether they poor would, in your own words, but under a death sentence. The latter is not obvious to me. The more rich people are in any health system, the better off the poor are. The poor may be even better off if rich pay pay for all those nice hospitals *and* they get welfare, but the important step is a wealthy economy with lots of rich people spending a lot of money on their own health care. That is always and everywhere a net plus for the poor.

Who is talking about a totally unregulated health care system? What I pointed out is that the Republicans and Democrats have both, over decades, screwed up the health care system. A problem for which Obama is now promising even more regulation and hence even more unforeseen consequences. I can see why you would want to take the cheap shot, but really, is that sensible?

I do not believe that equity ought to be a desired outcome in any health care system. Quality ought to be. America has a poorly designed system for the elderly which has worked well because most doctors are honest and because America has not had too many old people. That is about to change and the system is not sustainable in the long term.

It may be possible to design a system that would be cheaper. Singapore’s model is an excellent one. But that is not what is on offer so it is not relevant. Obama wants more regulation and will inevitably push up costs. Britain thought the NHS would be cheaper. It wasn’t. Not even remotely. Obamacare will be no different. So there is no point talking about unicorns when they don’t exist.

Now I suppose we have agreed you support regulation in health care, the only question is how much. To my mind, you either want free markets in health care, because you think it effectively operates as a commodity good, or you don’t. Clearly the state of the pre-Obamacare U.S. system is inadequate for many Americans. But you would fix that with less regulation? I don’t buy it.

All those rich people incentivizing the creation of specialty, high-priced cancer hospitals, boutique clinics, and useless me-too pharmaceuticals helps the poor? You can have strong public programs that incentivize health care innovation and infrastructure development by paying for the right treatments, but it is not necessary for rich people to do that. That is the way it works now. Any device or drug maker’s first marketing calculation is based on whether they think Medicare will reimburse for their product, not whether the wealthy will like it.

On the NHS–it does better than the U.S. system on the a lot of measures and it doesn’t include the shame of millions of people without coverage for services. It is also much cheaper. The good thing for rich people is that there will always be a parallel market for Cadillac health care that operates largely outside the public programs. This works quite well for them in the UK.

If you are interested in health care quality, see this fact sheet on how Obamacare will improve it: http://assets.aarp.org/rgcenter/ppi/health-care/fs197-health.pdf I have not seen any decent proposals from the other side that do as much to promote quality. One benefit of the ACA is its flexibility. It takes into account that there is a lot of learning yet to come on quality and it is designed to evolve and incentivize effective practices. Accountable Care Organizations will be built on the idea that quality is the priority.

I don’t understand your point that honest doctors have made Medicare work so far. I agree they are generally honest, and Obamacare will help them to move away from the rigid fee-for-service only approach that many physicians know is not the best way to do health care.

Jan, “will improve it” or “could potentially improve it”? The second would be more honest, otherwise I’d like to ask the AARP how they got their hands on a functional crystal ball. I think SMS makes a good point with Singapore’s health care model, and am curious why you continue to ignore it.

Some of the principles of the Singapore system make sense for basic care, but I have little hope they could be transported here. E.g. Yes, please try to mandate that people here save 20% of their income (along with employers kicking in 13%) for health care. I think that would go over well.

I am all for making people pay more out of pocket unnecessary or more elective procedures. We just need to know which treatments those are that are low-yield, so we need PCORI to be effective.

Good for the Republicans – the regulatory state is completely out of control. Too many decisions are delegated to the unelected and invisible, and Obamacare is a particularly egregious example. Let’s have more sand in the gears, please!

The bottom line that Berger is fingering is that both parties have shirked their responsibilities as our political representatives and have, since the 1960’s, passed those duties to the unelected and opaque regulatory state. People that claim that IPAB will save Medicare are essentially declaring that the people are not responsible enough to elect people who will tell them when grandma should sent to the hospice to die.

Congress can and should decide the rules (some sort of cost/benefit analysis with a budget constraint) for when gramma is sent to the hospice. Congress cannot very well decide case by case; that’s why the Constitution provides for an executive department.

This is correct. It’s also why the Republicans backed away from the individual mandate, which was their idea, and why they will not even accept the CPI adjustment and means testing that Obama is willing to give them.

And of course if someone proposes a dumb idea and you say “well, that’s kinda dumb, but here is how you could make it a little less dumb” that doesn’t = that ‘little less dumb idea’ is your best idea, or even that “it was your idea in the first place, this little less dumb idea!”

It was, and they have tried really hard to backtrack on it but see the USA Today op-ed that Andrew’ links at the bottom of the page. That is the best they could do. Really amazing when you think of the garbage alternatives the free marketers and Republicans have served up the past few years.

The individual mandate makes a lot of sense to me. It seems very similar to car insurance. In my way of thinking once Reagan said we could not turn people away at hospitals that pretty much required everyone to have insurance to be able to pay for the services they may require. I guess you could argue that you don’t really need insurance you just need finances available but given the unlikely event of having a medical emergency it seems like requiring insurance rather than a large cash reserve makes sense. The other option that completely makes sense as well is to take away the requirement that hospitals have to keep people alive. Then they could check to see if the person has the funds to pay before performing any services. Either way is fine with me but seems like you have to choose one or the other.

And I agree Heritage != Republicans but does RomneyCare = Republicans? And does RomneyCare = Heritage? If A=B and A=C does B=C?

“The individual mandate makes a lot of sense to me. It seems very similar to car insurance.”

But it’s not. 2 ways. 1, I don’t have to drive. Or I can drive a motor scooter. There should obviously be less liability for a lighter mass. That would be reality-based policy. 2, THIS IS WHAT HERITAGE SAYS. They offered the idea as a kind of liability. OBAMA OFFERS THE IDEA AS COMPREHENSIVE. THAT IS HOW IT IS DIFFERENT.

On #1 I agree. Just take away the requirement that a hospital has to save you if you fall down in the shower and bang your head and we are good (again thank that liberal Reagan for that).

On #2 in theory I agree with you again that government provided insurance should be aimed at catastrophic coverage rather than comprehensive coverage. In practice I get the feeling that people are using emergency rooms for basic care so this doesn’t work.

I couldn’t agree more!
Why would anyone agree with an idea, no matter how good it is for the people, unless they themselves came up with it?! Selfish democrats just want to continue their reign of power and try to influence the votes of the poor and middle class (who they don’t care for obviously, and its really just to earn votes). I mean, who could really care for anything but money or power…right?
Its about time the Republicans stand strong and make it a point to make sure everything under this administration fails so that American can be returned to the rightful position of conservative morals. We just need to bunker down and let the country fail until America votes our way. Take our country back from the minorities that are abducting it right? You know, its called a white house… right?
Oh man, ignorance is a slippery slope…. right?

Sure, and demographics will make the Republican party a non-factor in national politics soon enough anyway, but then what? The fact that the Democrats are in complete control in California hasn’t exactly produced great governance.

Hear, hear. The innovative benefit of the IPAB/Obamacare “Medicare savings” were always vastly overrated compared to prior law. We already had a panel of experts to decide Medicare reimbursement rates, and a set of predetermined spending targets everybody ignores that mascarade as “cuts”.

Even Dems vote overwhelmingly to overturn the SGR year after year, and there’s no reason to believe that they’re gonna change their longstanding habits.

The fundamental problem is politician’s belief that they can cut Medicare without cutting benefits. You hear Dems repeat this talking point constantly. It is economically illiterate.

As for cutting “entitlements” to doctors and hospitals, if they continue cutting reimbursements, you won’t be able to find a doctor that takes Medicare. You already can’t hardly find a specialist that takes Medicaid. As a foster parent with children in the house with Medicaid, it’s virtually impossible to find care for anything that requires a specialist without driving the child to a big city. I live in a town of about 100,000 people, so it’s not like I live in a really small town.

WOW!, a rare species on this blog’s comment section, saome real world experience. This is a blog for fairly smart, well educated, predominatly male, mostly white, 10 percenters, to vent their intellectual chops on abstract argumanets that align with their tribal interest, with an occasional good argument put forward. glad to see you here adisorganizedmom, your a welcome addition.

Don’t worry about financing Obamacare though…
” So supporters — including Rep. Jerry Nadler (D-N.Y.) —say that President Barack Obama should order that a couple of platinum trillion-dollar coins be made and then have the coins deposited in to the Fed and, voilà, debt ceiling crisis averted.”

Still trying to wrap my head around the idea of some physical thing being imbued with the property of being “money”. I mean there is nothing special about calling gold money instead of any other physical thing. I guess it makes sense to use a metal since they last longer but you’d think the physical thing you chose would at least have some usefulness. Gold does have some uses as an industrial metal but certainly its price is not tied to its natural value. At 42 maybe I have only lived in times where money was an abstract concept so trying to tie it to something physical just doesn’t click with me.

Please reread. The whole point of my comment, which you seem to have missed, is that the Republicans are now (again) against a proposal very similar to one Ryan made, and they generally approved of, fairly recently. So I conclude that the main reason they don’t like it is that it came from Obama, rather than that they truly think it’s a bad idea.

I would be glad to see that particular piece of Ryan’s plan substituted for IPAB, even though it is a Republican proposal.

This has become a nice mini-theme of this blog over the past year or so: Republicans being forced, or forcing themselves, into taking positions that argue for greater governmental domestic spending or obstructing the cutting of such spending.

I’m not sure why this is hard to understand. It’s not just government spending on their usual wacky nonsense. It is akin to the government sending our military overseas and THEN cutting funding for bullets.

Let’s try this: If you want to NOT create a new government spending program, that’s great. Sign me up. If you want to co-opt a legitimate market, nay claim it is the MOST legitimate market and in fact too important NOT to co-opt, and monopolize payment and then cut payment willy-nilly, that’s NOT cool.

If no doctors accept Medicare that seems to solve the funding problem since it will no longer need any funds. And then people will actually be competing for the doctors that don’t take Medicare to get the services using their own money instead of the governments. I don’t see any downside to what is going on here. Republicans should always be arguing for decreased payments from government supported programs since those cuts will force people back to the private system. The private system being the system that always exists and everyone has the option of using at any time. I am pretty sure Warren Buffett is not using Medicare.

As described in the article, the rule appears to require congress that pass legislation in accordance with the wishes of a previous congress, aka “binding a future congress”, a practice illegal under well established case law. Regardless of your position on the legislation involved or Republicans’ reason for refusing to follow this rule, they’re doing the right thing. You may wish they’d do something different, but if this practice were to become the norm you’d bitterly regret it down the road

Congress can pass a debt ceiliing; they cannot require a future Congress to do so, nor can they enjoin a future Congress from repealing or modifying a debt ceiling they passed. The exception to this would be if Congress succeeded in amending the constitution, though even then a future Congress could repeal the amendment via the same mechanism, or modify legislation passed by a previous Congress within the parameters of that amendment.

I’m no fan of the debt ceiling, but this is not quite right. In Article I, Section 8, Congress is given the power “To borrow money on the credit of the United States.” The implication is that the Executive Branch (e.g. the Treasury) needs the explicit permission of Congress before it can borrow money on the credit of the United States. The American practice (since, I think, World War I) is for Congress to pass blanket enabling legislation allowing the Treasury to issue debt whenever it needs to but only up to a certain limit. When that limit (e.g. the “debt ceiling”) is reached, Treasury must go back to Congress and request a higher limit before it can issue more debt.

So the debt ceiling — as silly as it is in a world of modern budgeting and public finance — is not a matter of a past Congress binding the ability of a future Congress to spend money. Instead, it is simply a limit only on issuing public debt. If the Treasury has other ways to pay for government spending (which it does not at present), it can still spend as long as its spending is within the law.

I’m not sure that that would be the worst thing in the world. We are already bound by the intended and unintended consequences of entitlements. If a cost cutting measure that was central to the savings of the ACA is not implemented then we will only continue to spend unchecked. This is not making congress pass any laws merely expediting the process and keeping costs down. Affirm. Why? Trying to fly in to see me or need a ride home?

“The healthcare law says the House must begin taking up the IPAB’s recommendations as soon as they’re made, and requires House committees to pass them quickly.”

This is requiring Congress to take specific action on legislation passed by a previous Congress.

“Congress can only change the IPAB’s recommendations if it comes up with the same level of savings elsewhere in the budget.”

This enjoins Congress from altering a law passed by a previous Congress.

As I said, as described in the linked article, legislation passed by a previous Congress both requires the present to take legislative action on some issues and enjoins or restricts it from taking legislative action on others. Congress has absolutely no legal obligation whatsoever to comply with either.

No doubt it wouldn’t be the worst thing in the world in some cases. I’m simply saying it’s illegal. I guarantee politicians you disagree with will control Congress at some point. Do you really want them to have that power?

“If a cost cutting measure that was central to the savings of the ACA is not implemented then we will only continue to spend unchecked.”

““The healthcare law says the House must begin taking up the IPAB’s recommendations as soon as they’re made, and requires House committees to pass them quickly.” This is requiring Congress to take specific action on legislation passed by a previous Congress.”

Well, that’s what it’s trying to do, but it clearly isn’t “binding” in any meaningful sense because if the 114th Congress doesn’t want to follow a rule passed by the 113th, it can just repeal that rule. There’s nothing the 113th can do to stop them. Hell, Congress can repeal the entire US Code tomorrow, if such is its whim, thereby undoing the work of every previous Congress in history.

“The IPAB is a panel of 15 healthcare experts (me: 15, WTF?) , which will recommend targeted savings if Medicare spending rises above a certain rate. The panel is not allowed to cut Medicare benefits. (me: huh?)
The healthcare law says the House must begin taking up the IPAB’s recommendations as soon as they’re made, and requires House committees to pass them quickly.
Congress can only change the IPAB’s recommendations if it comes up with the same level of savings elsewhere in the budget.”

Unfortunately, this it is simply rightward trending ideology, not new evidence that has changed the author’s mind about an individual mandate. His explanations for changing his position are skimpy and based on a couple nitpicky technical interpretations. Weak.

“the new field of behavioral economics taught me that default auto-enrollment in employer or nonemployer insurance plans can lead many people to buy coverage without a requirement”

This is awesome. You know if we don’t tell people it isn’t required but we do automatically enroll them in an insurance program turns out they aren’t smart enough to figure out how to turn the thing off. The Republican, I mean Heritage, plan is great.

“advances in ‘risk adjustment’ tools are improving the stability of voluntary insurance”

I completely agree the private insurance industry is getting better at making money. They did get ObamaCare passed right?

“I agree with my legal colleagues at Heritage that today’s version of a mandate exceeds the constitutional powers granted to the federal government. Forcing those Americans not in the insurance market to purchase comprehensive insurance for themselves goes beyond even the most expansive precedents of the courts”

But apparently Reagan’s requirement that hospitals treat patients that don’t have any money did not exceed constitutional powers? Hmmm… something is not right here.

Even if the preferred outcome is free market health care, that doesn’t inform us of what to do when stuck in a system of price controls. If you lower the price ceilings, suppliers leave the market and, in this case, that means people suffer and die. If you keep the price ceiling above the market clearing price, you spend more money, and there is less suffering and dying (including some that market participants would have chosen on there own).

Short version: Medicare can only function as long as they keep setting prices (in most cases) above the market price. Slashing the price controls will not bring about free market health care, it will create shortages. Which will lead to death and suffering.

Confused here… no one has to use Medicare. You can always purchase private insurance or just pay for services out of your own funds. It is the doctors’ choice to accept Medicare or not. If they don’t want what the government pays they instead get what private insurance is willing to pay or what individuals directly are willing to pay.

True, nobody has to use Medicare. However, the millions of voters who spent their working lives paying Medicare taxes and were promised Medicare benefits, tend to get pissy when they can’t find a doctor who accepts Medicare.

I have this time machine. It’s about 5-20 years out. My dad who used to tell me how we have the best system on Earth yesterday said “I wish they’d never created Social security.” My time machine is about 10 years ahead of him and about 20 years ahead of the Democrat party.

This is the whole point of the catch-22 for the Republicans. By cutting benefits we help to reduce the program and this whole idea of “i am owed this stuff from the government” goes away. If we don’t cut the benefits then the program is here to stay. You can’t have it both ways.

I often argue out of both sides of my mouth on here because as long as you have an intellectually consistent idea I consider it a viable choice. It may not be the choice I would make it but I at least consider it a reasonable position. From what I have seen over the past 10+ years it just doesn’t seem like Republicans are intellectually consistent. That I think is the point of these posts by Tyler.

So how are we ever going to get rid of it then? You have got to cut it sometime right? Why not right now?

My belief is doctors are vastly overpaid (this goes with my belief that pretty much all US industries that have shielding from global/automated competition are vastly overpaid). I could be wrong but it seems like RNs can do 95% of the jobs doctors do. Surgical specialists should make some money I agree. But as we slowly move toward automated surgery those costs should go down as well.

But why blame Republicans for not explaining it effectively to voters. It’s like people like Scott Sumner set the entire Democrat majority to one side and says “okay, they are only the 50%, now let me blame the 1% that caves to them.”

The problem is that Obama isn’t cutting medicare. We are talking about the part that benefits the Republican constituency. That’s all Obama wants to cut.

“The problem is that Obama isn’t cutting medicare. We are talking about the part that benefits the Republican constituency. That’s all Obama wants to cut.”

Maybe… like you said it needs to be explained more effectively. And like I said part of my reasoning comes down to I think doctors are way overpaid as it is so that biases me towards saying stop milking the Medicare cow.

@Steve,
Likely we won’t. But if we were to, I don’t see how we could just “cut it” because the “cut spending” action of the government is actually the imposition of a massive (downward) price control on the medical supply side. They need to change the regime as a whole, but likely start with significant regulatory overhaul.

Now, you might think doctors are vastly overpaid, but even if they were, that doesn’t mean that simply cutting their payments would result in a small decline in the Q supplied. Of course you’re right that there are cheaper ways to do what doctors do, but much of the expense incurred by doctors, medical overhead, the fact that sometimes doctors do what nurses could and computers might is driven by… regulation and mandate.

So what we’re left with is a situation in which
1. The government limits supply of medical services through myriad regulations that result in “doctors being vastly overpaid”.
2. To induce people to be doctors, we then must pay well above the market price (which, in fact, we do).

Solution: Massive deregulation of the supply side has to happen first. If it can be carried out, prices fall on their own and the government can stop paying as much. But stopping payments while continuing to enforce the status quo of the supply industry = shortage.

The problem is that Obama isn’t cutting medicare. We are talking about the part that benefits the Republican constituency.

Republicans are all for small government except when it comes to cutting the parts that benefit them. Of course, the parts that benefit them disproportionately make up about 65% of the budget (SS, Medicare and Military). That’s just the three big programs. It explains why they are always just gunning for Medicaid.

Republicans, excuse me, conservatives, excuse me, “small government independents” have always been about “getting their’s” over anything else. Andrew’ can look back and see all these colored left wing people at the bottom of the demographic period and does anybody think he will give two damns whether or not there’s any medicare or social security left for them? Republicans want to extract as much out of the system while they can.

“Solution: Massive deregulation of the supply side has to happen first”

This does make sense. From my point of view antibiotics are the only thing stopping deregulation of the medical industry (possibly there are others that require regulation but antibiotics are the only things that I am aware of that are critically important). It is pretty much impossible to tell if you have a good or bad doctor right now so I don’t think deregulation would make it much worse. If only there weren’t problems with overuse of antibiotics it would seem like a great solution. If we could make it so that antibiotics were the only drugs requiring a prescription we would probably lower costs very quickly.

People seem very confused about how Congress works. It’s pretty simple: Congress can pass whatever laws it likes, without regard to past Congresses. Past attempts to bind current Congresses have no force, nor is there any such thing as “mandatory” spending (every entitlement could be legislated out of existence tomorrow).